Provider Demographics
NPI:1841887833
Name:PROGENITOR MDX, INC
Entity type:Organization
Organization Name:PROGENITOR MDX, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:R
Authorized Official - Last Name:SAMS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:877-502-4748
Mailing Address - Street 1:675 S ARAPEEN DR # 103B
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1223
Mailing Address - Country:US
Mailing Address - Phone:877-502-4748
Mailing Address - Fax:
Practice Address - Street 1:675 S ARAPEEN DR # 103B
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1223
Practice Address - Country:US
Practice Address - Phone:877-502-4748
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-24
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physicianGroup - Single Specialty